Greatskinohio.com

Skin Care History Questionaire and WaiverPlease answer the following questions so that your Skin Care Specialist may have a better
understanding of your general health and lifestyle, thereby enabling your Skin Care Specialist to
accurately analyze and assess your skin care needs.
Name: ___________________________________________________________Date: _________________________
Address: _________________________________________________________________________________________
City: _________________________________________________State: ________________ Zip: _________________
Home Phone: __________________________________ Business Phone: _________________________________
Cell Phone: ________________________________________ Date of Birth: ________________________________
E-mail address: ___________________________________________________________________________________
What type of work do you do? ___________________________________________________________________Have you seen a dermatologist in the past year? Yes________No________If yes, list dermatologist’s name, contact info and reason for visit____________________________________
__________________________________________________________________________________________________
Are you presently under a physician’s care? Yes________No________If yes, list physician’s name and reason for visit _____________________________________________________
__________________________________________________________________________________________________
Are you currently taking any medications? Yes________No________ If yes, please list __________________
__________________________________________________________________________________________________
What is your genetic background? ________________________________________________________________
How is your general health? ______ Excellent ______ Good ______ Fair
Please rate your stress level from 1-5 (5 being the highest): __________
Please circle the following conditions you have or had experienced:
•hypertension•contact lenses•high cholesterol•asthma •metal plate•anemia•varicose veins•hepatitis•diabetes•lupus•seizures•tooth fillings•fainting•irregular pulse•eating disorder•high/low blood •cold sores•claustrophobia•heart attack•hernia•cancer•epilepsy•autoimmune disorder•stroke•thyroid disorders•headachesAllergies:
Have you ever had an allergic reaction to any of the following:ASPIRIN OR SALICYLATES
If checked yes to any of the above, please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list any other known allergies: __________________________________________________________________________________________________Have you ever had Herpes Simplex?
If yes, have you ever been treated with Denavir® (Penciclovir), Zovirax® (Acyclivor) or Abreva?Yes_______ No________Are you being treated for Hepatitis?
Female clients only:
Are you presently taking birth control pills?
Skin Care HistoryAre you currently having skin treatments? Yes________ No________If yes, what type of treatment(s)___________________________________________________________________Please check if you are presently using or have used in the past any of the following:________ Benzoyl Peroxide (BP)________ Glycolic Acid (AHA)________ Lactic Acid (AHA)________ Resorcinol________ Salicylic Acid (BHA)
Do you have or have you had any of the following in the last 14 days?________ Facial Cosmetic Surgery________ Botox Injections ________ Collagen Injections________ Fillers________ Light Treatments________ Laser Resurfacing ________ MicrodermabrasionOther ____________________________________________________________________________________________
HOME CARE:What Skin care products are you currently using at home?Cleanser _________________________________
Vitamin C ______________________________________
Toner ____________________________________
Exfoliants/Scrubs ________________________________
Moisturizer ________________________________
Specialty Products ______________________________
SPF _______________________________________
Mask ___________________________________________
PRESCRIPTION PRODUCTS:________ Tretinoin (Retin A, Retin-A Micro®, Renova, Avita)
________ Azelaic Acid (Azelex®, Finacea™)
Any other topical antibiotics_______________________________________________________________________
PLEASE CHECK IF YOU ARE PRESENTLY EXPERIENCING OR HAVE EXPERIENCED ANY OF THE FOLLOWING:________ Skin Cancer
Do you sunbathe or participate in outdoor activities?
Have you tanned in a tanning booth in the last 14 days?
Have you had any direct sun exposure in the last 10 days?
WHEN EXPOSED TO THE SUN DO YOU:________ Always burn, never tan
________ Always tanDo you feel your skin is sensitive?
WHAT SKIN CONDITIONS DO YOU WANT TO IMPROVE?________ Acne and/or breakouts
________ Hyperpigmentation (freckles, age spots)
OTHER ____________________________________________________________________________________________
Is there any other necessary information your Skin Care Specialists
should know before beginning your treatment?
If yes, please explain _______________________________________________________________________________________________________________________________________________________________________________
I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment and home care products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s). I understand I need to sign this waiver prior to every treatment provided, with ANY changes pertaining to the Client Signature: __________________________________________Date:_______________________________Client Signature: __________________________________________Date:_______________________________Client Signature: __________________________________________Date:_______________________________Client Signature: __________________________________________Date:_______________________________Client Signature: __________________________________________Date:_______________________________Client Signature: __________________________________________Date:_______________________________Client Signature: __________________________________________Date:_______________________________
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glō•therapeutics Treatment RecordCLIENT'S NAME: ___________________________________________________________DATE: ____________________________CLIENT'S CURRENT SKIN CARE PRODUCTS: __________________________________________________________________________________________________________________________________________________________________________________TREATMENT PROVIDED________________________________________________________________________________________AREA TREATED: __________________________________ HOW MANY LAYERS / TIME LEFT ON SKIN: _____________________PRODUCT USED TO PREP SKIN: Peel Prep
MASK: None Soothing Gel Mask Calming Seaweed Mask Restorative Mask Refining MaskADDITIONAL PRODUCTS USED:__________________________________________________________________________________RESULTS: Redness Hot Spots Frosting OtherCOMMENTS: __________________________________________________________________________________________________
CLIENT'S NAME: ___________________________________________________________DATE: ______________________________CLIENT'S CURRENT SKIN CARE PRODUCTS: ______________________________________________________________________________________________________________________________________________________________________________________TREATMENT PROVIDED__________________________________________________________________________________________AREA TREATED: __________________________________ HOW MANY LAYERS / TIME LEFT ON SKIN: ______________________PRODUCT USED TO PREP SKIN: Peel Prep
MASK: None Soothing Gel Mask Calming Seaweed Mask Restorative Mask Refining MaskADDITIONAL PRODUCTS USED:__________________________________________________________________________________RESULTS: Redness Hot Spots Frosting OtherCOMMENTS: __________________________________________________________________________________________________
CLIENT'S NAME: ___________________________________________________________DATE: _______________________________CLIENT'S CURRENT SKIN CARE PRODUCTS: ______________________________________________________________________________________________________________________________________________________________________________________TREATMENT PROVIDED__________________________________________________________________________________________AREA TREATED: __________________________________ HOW MANY LAYERS / TIME LEFT ON SKIN: _______________________PRODUCT USED TO PREP SKIN: Peel Prep
MASK: None Soothing Gel Mask Calming Seaweed Mask Restorative Mask Refining MaskADDITIONAL PRODUCTS USED:__________________________________________________________________________________RESULTS: Redness Hot Spots Frosting OtherCOMMENTS: __________________________________________________________________________________________________

Minutes of European ALMA Board Meeting held on 20 February 2003 at ESO Garching Participating by telephone, joining during Item 3: R. Wade Attending for Item 6 only : S. Stanghellini 1. The Board adopted the Terms of Reference agreed by Council. These are attached for reference, with the date of adoption noted. 2. The Board agreed the Agenda EAB 2/03 3. Notes of meeting on